Sural Nerve Entrapment Explained | | Chronic Body Pain Foot Pain Sural Nerve Entrapment Explained Before we can discuss what sural nerve entrapment is, you really should know what the sural nerve is and what it does. The sural nerve is also referred to as the short saphenous nerve. It is the sensory nerve located in the lower leg. This nerve lies very close to the short saphenous vein, which is a major vein located in the calf. The sural nerve can begin from just behind the knee to just below the ankle. This particular nerve is often used for nerve grafts and biopsies. The sural nerve begins and the juncture of the lateral and medial sural cutaneous nerves. In most individuals, this typically occurs very low in the leg- even at or below the ankle in some cases. On the other hand, in a few individuals, the sural nerve can begin as high as behind the knee. , in some individuals, the sural nerve is actually simply a continuation of the medial sural cutaneous nerve.

This nerve travels down an individual’s calf just below the surface of the skin, passing close to the Achilles tendon and then ending in the space between the heel and the bony bump on the outside of the ankle, known as the lateral malleolus. It actually continues into the foot, reaching the little toe- but once it passes the ankle, it is given a different name- the lateral dorsal cutaneous nerve. The sural nerve conveys sensory information regarding the lower calf and outer foot to the brain- damage to this nerve can result in extreme pain in the leg or foot. However, if damage does occur, it can be treated by removing part of the nerve. Of course, removal of a portion of the nerve can result in numbness in the ankle and side of the foot- but the nearby nerves will grow in to compensate, which restores most of the feeling to the area. Due to the fact that the sural nerve is just below the skin and it’s basically not important to essential bodily functioning, it is often used when a nerve biopsy is necessary.

To perform a biopsy, the surgeon will inject a local anesthetic and then, using the short saphenous vein to guide him/her, will locate the sural nerve and then remove a piece about an inch long. The wound will then be stitched closed and then covered with gauze moistened with saline. The sample will then be placed under a microscope and examined for evidence of nerve disorders. Additionally, this nerve is often chosen to be used in nerve grafts. This is where a piece of the nerve will be taken out and transplanted into an area where nerves have been damaged. The donor piece will be spliced with the existing nerve to restore muscle functioning and sensation. This procedure is commonly used to restore the feeling in damaged limbs. The sural nerve is being transplanted more often into the pelvic area after prostate surgery to restore any lost sexual functioning. Sural Nerve Neuropathy Though the sural nerve is not necessarily essential to bodily functioning, it is still a nerve, and just like other bodily tissues, can experience disease and/or trauma. The sural nerve is a peripheral nerve, meaning that it serves to communicate with the brain and spinal cord. Sural nerve damage is a subtype of peripheral neuropathy.

There are some important characteristics of sural nerve damage related to the functioning and the anatomy of the involved structures. Types of Neurons and Related Anatomy Nerve cells, also referred to as neurons are divided into three major categories: Sensory Motor Interneurons The sensory neurons pick up the sensory signals and then take them to the spinal cord and the brain. On the other hand, the motor neurons take commands from the spinal cord and the brain and carry them to the muscles or glands to tell them what to do. However, no matter what their primary function, all neurons have the same specific structural components: Cell body Axon Dendrites The cell body holds the nucleus and is the center of the metabolism of the neuron. The axon is a very long fiber of nerve that carries the signals away from the cell body. The dendrites are short projections that carry the signals that are coming into the cell. The axon is often covered by a myelin sheath. Types of Peripheral Neuropathy Basically a nerve is a corded bundle of axons. There are a few forms of neuropathy: Mono-neuropathy Poly neuropathy Mono-neuropathy is basically a neurological disorder that is caused by a single nerve malfunctioning.

However, when several of the nerves become dysfunctional at the same time, it is referred to as polyneuropathy. Experts have agreed that widespread peripheral neuropathy, also referred to as polyneuropathy, very often involves the sural nerve in some way. However, true mono-neuropathy, or isolated sural neuropathy is a very rare condition. Causes of Sural Nerve Neuropathy One study that was featured in “Muscle and Nerve” clinical journal claims that trauma is the most common reason for sural nerve neuropathy. Possible causes of trauma include fracture of the ankle, sprained ankle, stripping of veins, surgery of the knee, running for long distances, laceration of the ankle, gunshot to the ankle and external compression. Experts claim that compression could be due to tears of the calf muscle or overgrowth of the muscles. Some other causes of sural nerve neuropathy include: blood vessel inflammation, also referred to as vasculitis; biopsy of the sural nerve; diabetes; and ganglion cysts.

Due to the fact that the sural nerve is so close to the surface of the skin, it makes it much more likely to become injured due to compressions on the skin and the fact that most injuries occur on the surface of the skin. Signs and Symptoms of Sural Nerve Neuropathy Nerve damage- and the signs and symptoms of that nerve damage- can actually occur anywhere on the sural nerve. Sural nerve neuropathy often means that the individual will experience pain and other abnormal sensations in the skin of the ankle and foot, including tingling and numbness. In most cases, these feelings will be much worse in the evenings and at night- even to the point of causing disruptions in sleep. Some of the other common symptoms of sural nerve neuropathy include shooting spasms, burning, hypersensitivity to the area, pain, numbness, and even weakness in the area surrounding the nerve. An individual with sural nerve neuropathy may also experience a reduction in motor functioning. Diagnosing Sural Nerve Neuropathy There are several different diagnostic procedures used to diagnose peripheral neuropathy, including sural nerve neuropathy.

Neurological testing Nerve/skin biopsies Imaging However, you should be aware that isolated sural neuropathy is often much more challenging to diagnose than other forms of peripheral neuropathy and will also require additional testing including an electro-physiologic evaluation. Treatment of Sural Nerve Neuropathy Surgical release has been claimed to be the best possible treatment for sural nerve neuropathy that is due to compression or entrapment of the sural nerve. Sural nerve neuropathy that is connected with problems with the ankle may also require some physiotherapy, reconstruction, or bracing. Basically, just as with any other disorder, the key to managing sural nerve neuropathy is to control or even get rid of the causes by treating the underlying disease and addressing any behaviors that could be causing or contributing to further damage to the nerve. Nerve Entrapment and Athletes Very often, athletes will complain of having leg pain and problems. Typically, these conditions are due to entrapment of the sural nerve or even other peripheral nerves. Of course, we all know that leg pain caused by exercise is a very common condition and has lots of different apparent causes.

In many cases, leg pain that is caused by exercising is due to many different reasons, and can be localized or can be a great distance from the pain site. Once a physician has ruled out things such as musculoskeletal problems, vascular problems, and even compartment syndrome problems, the symptoms of nerve entrapment should come into play as a potential cause of the leg pain. Non-neural Causes of Leg Pain There are several different non-neural reasons an individual could experience leg pain. They are as follows: Shin Splints The term shin splints actually covers a variety of disorders that could be a result of leg pain caused by exercising. In the beginning, “shin splints” were thought to be a result of an injury to the tibialis posterior tendon. Other conditions involving overuse have also been wrongly called “shin splints,” such as: Compartment syndrome Tibialis anterior strain Tibial stress fracture Due to the fact that the above conditions have totally different causes, the term “shin splints” is not a very useful term. Instead, the physician should seek to find and address the specific condition that is present. Muscle Strain You may not know this, but you can actually damage your muscles by overstretching them.

The muscle that is most often injured due to overstretching is the tibialis anterior, in front of the shin. Symptoms of a muscle strain are as follows: acute pain in the muscle where the tear is, swelling, and inflammation. Once the swelling has reduced, you should treat this condition by stretching and strengthening the muscle that is affected. However, make sure to stop when you’re experiencing pain. Tendonopathy Tendonopathy is a condition in which microtears in the tendon result in inflammation in the surrounding tissue. This is another “overuse” injury that is most often caused from excessive repetitive movements, mostly overstretching a muscle. When it comes to the leg muscles, the one that is most often affected is the tibialis posterior, usually due to repeated hyperpronation. Symptoms of Tendonopathy include swelling, pain, and a “crunchy” feeling, or palpable crepitus on the tendon during contraction of the muscle. The pain will typically happen at the beginning and just following exercise. When beginning treatment, painful activities should be stopped and you should start taking anti-inflammatories.

Of course, you should be aware that you should not cease all activities and completely rest because tendons truly do heal much more effectively when they are given mild loading. Once the pain and inflammation have reduced, the affected tendon should be strengthened and stretched. Medial Tibial Stress Syndrome One of the natural consequences of weight bearing is bone bending. Of course, the wider bones are much more resistant to bending than the narrower ones and therefore, that makes them much less likely to become injured. Repetitively bending bones causes a long bone to widen its cross section by causing the cells to lay down new bone. If the intensity of training increases during this process, the cells of the bone are not able to keep up with the growth and therefore the area will begin to experience inflammation. This particular injury could also be made much worse by simultaneously and repetitively pulling the muscles of the periosteum. With this injury, the area this is most likely to become affected is the lower half of the medial tibia, where the cross section of the bone is the most narrow. Signs and symptoms of this condition include pain during weight bearing activities- especially running, as well as tenderness. In some cases, you may notice redness, warmth, and even swelling.

Treatment for this condition is full rest from painful activities, slowly and gradually returning to normal training. You should not be strengthening or stretching your muscles while experiencing symptoms. Tibial Stress Fracture A tibial stress fracture is an incomplete crack in the tibia when repetitively putting a load on the bone has decreased its ability to support the load. This condition is much more likely to occur in specific sports such as with long-distance running. Once a tibial stress fracture has been diagnosed, an individual should completely rest for at least 15 days from weight bearing activities. Though it is very uncommon, an individual who does not rest could experience spontaneous complete fractures. In most cases, a tibial stress fracture will heal in about four to eight weeks. However, lesions on the front of the bone could actually take several months to heal and could end up requiring grafting or electrical stimulation. It is very common for a tibial stress fracture to reoccur. Chronic Exertional Compartment Syndrome Chronic exertional compartment syndrome is an overuse condition that is a result of tight fascia around the muscles, producing symptoms during training and up to around 15 minutes after training.

In most cases, this condition is characterized by a tightness in the rear lower leg, as well as feeling of pins and needles. The diagnosis can get a confirmation by using pressure testing after an individual exercises. Often, the individuals describe the pain as a cramping feeling. There may also be some muscle tears present. In some cases, a physician will recommend using elective fasciotomy in order to release the fascia and therefore reduce the pressure. This condition should not be confused with acute compartment syndrome, as the latter is a medical emergency that can happen after being hit in the lower leg directly. Popliteal Artery Entrapment Syndrome This is an extremely uncommon condition that is found among young individuals involved in sports that have a signs and symptoms of restricted blood flow to their lower leg. These indications are pain, paresthesia , and pallor. This condition is due to intensity of exercise and drops away very quickly upon cessation. Upon a post-exercise examination, a physician will most likely find arterial bruits, which is sounds of local blood flow using a stethoscope, and diminished or even an absent pulse. Compression could possibly happen at the start of the medial head of plantaris or gastrocnemius due to the artery taking the wrong course.

Surgically removing the structure causing the compression is usually suggested as an effective treatment. Nerve Entrapment Syndromes The term “peripheral nerve entrapment” refers to the mechanical irritation in which a specific peripheral nerve becomes injured in an anatomical location that is vulnerable. Nerve entrapments cause a disturbance in the functioning of the nerve. Nerve entrapment could possibly occur at any site due to tissue damage, including tumors, hematomas, or fractures. There are several sites which the peripheral nerves are in confined spaces and therefore at a much greater risk of becoming compressed. Physicians treating these conditions must also think about other causes of nerve entrapment including hereditary, inflammatory, degenerative, metabolic, and vascular diseases because these can also cause local nerve damage. Factors that can predispose an individual for developing nerve compression are repetitive actions that involve the extremity that is affected, RA, tenosynovitis, alcoholism, acromegaly, amyloidosis, mucopolysaccharidosis, diabetes, gout, deficiency in vitamin B, alteration in fluid balance, and even trauma.

In some cases, a nerve entrapment will seem very similar to compartment syndrome, Tendonopathy, and even arterial entrapment. Individuals experiencing this condition will often describe the pain as shooting and sharp. The condition can involve any combination of nerves. The best way to diagnose a nerve entrapment condition is to obtain a detailed history and performing a detailed, focused exam. The best time to test individuals for nerve entrapment is after they have exercised. The area should be carefully examined and if possible, palpate the nerve along its course to identify the site of the entrapment or injury. Of course, spinal and central problems must be addressed first and physicians should consider using diagnostic nerve blocks. Saphenous Nerve Entrapment Anatomy of saphenous nerve This is where the sensory branch of the femoral nerve goes down into the canal known as the adductor canal and then goes through the fascia over the Sartorius and then travels along the long saphenous vein. The two main branches of the saphenous nerve are the infrapatellar, which is located near the knee and the descending which is located near the inner end of the tibia bone.

Damage or entrapment of this nerve can be involved in conditions or injuries such as direct trauma, bursitis, and even MCL injuries. Additionally, damage can occur during surgery such as a hamstring graft to treat reconstruction of the ACL or even surgery to treat varicose veins. Individuals experiencing saphenous nerve entrapment will most often have knee pain , especially after working out their quadriceps. The pain could also be present at night and could be a burning pain. Treatment for saphenous nerve problems include injections of medications or even destruction and/or removal of the infrapatellar ranches of the nerve. Sural Nerve Entrapment This is a very rare cause of pain related to exercise, but still can occur. Compression due to various reasons such as mass lesions, ganglia, scar tissue, thrombophlebitis, and even surgical trauma can cause sural nerve entrapment/problems. Symptoms of this condition are very similar, if not identical, to those related to Achilles Tendonopathy. The nerve will be irritated much higher up and is often accompanied by a very small muscle hernia. Additionally, another symptom of this condition is post-exercise numbness.

Physicians prefer to treat this condition conservatively, with surgery working best only when a specific point of sural nerve entrapment has been pointed out. Sural nerve | definition of sural nerve by Medical dictionary Sural nerve | definition of sural nerve by Medical dictionary su·ral nerve [TA] formed by the union of the medial sural cutaneous from the tibial and the peroneal communicating branch of the common peroneal nerve, usually about the middle of the calf, although this is highly variable; thence it accompanies the small saphenous vein around the lateral malleolus to the dorsum of the foot as the lateral dorsal cutaneous nerve. Synonym(s): nervus suralis [TA], external saphenous nerve , short saphenous nerve sural nerve a nerve that originates high in the leg between the two heads of the gastrocnemius muscle and supplies skin on the lower posterolateral surface of the leg and the lateral side of the foot and little toe.

su·ral nerve (sūr'ăl nĕrv) [TA] Formed by the union of the medial sural cutaneous from the tibial and the peroneal communicating branch of the common peroneal nerve, usually about the middle of the calf, although this is highly variable; thence it accompanies the small saphenous vein around the lateral malleolus to the dorsum of the foot as the lateral dorsal cutaneous nerve. Synonym(s): nervus suralis [TA] . sural nerve ; lateral cutaneous nerve a terminal branch of the sciatic nerve; separates from main trunk in the popliteal fossa; subserves skin sensation at lateral side of lower part of leg, lateral malleolus and lateral aspect of foot distal to heel; palpable within superficial tissues immediately posterior to lateral malleolus (see injection) Sural Nerve Block: Overview, Periprocedural Care, Technique Periprocedural Care Overview Background Practitioners in the emergency department frequently encounter patients who have sustained trauma to the lower leg or foot and require anesthesia for repair.

The regional sural nerve block allows for rapid anesthetization of the posterolateral calf and laterodorsal foot, including part of the dorsal fifth digit. Regional blocks have several advantages compared to local infiltration, such as fewer injections required to attain adequate anesthesia, smaller volume of anesthetic required, and less distortion of the wound site. [ 1 ] Because of the lower number of injections, regional block is better tolerated by the patient and limits the chance of a needle stick injury to the provider. This procedure, often overlooked in the emergency department, is safe, is relatively easy to perform, and can provide excellent anesthesia to the foot and lower leg. [ 2 , 3 , 4 ] In one study, regional anesthesia of the foot and ankle, when performed by surgeons, was completely successful 95% of the time. [ 5 ] Because the sural nerve is relatively superficial, it is easily blocked at multiple levels at or above the ankle. In fact, because the nerve is so accessible, sural nerve biopsy specimens have been used to study inflammatory demyelinating peripheral neuropathies.

[ 6 ] Indications Indications for sural nerve block include the following: Wound repair or exploration of the lateral posterior calf or dorsolateral fifth digit As part of an ankle block required to manipulate a fractured or dislocated ankle Incision and drainage of an abscess in the lateral posterior calf or laterodorsal fifth digit Removal of a foreign body in the lateral posterior calf or dorsolateral fifth digit A combination of posterior tibial , saphenous , superficial peroneal , deep peroneal, and sural nerve blocks results in complete block of sensory perception beneath the ankle (see the image below). Areas of anesthetization to complete an ankle block. This block requires anesthetization of 5 nerves for complete sensory block below the ankle. The areas to anesthetize include a line along the anterior ankle for the superficial peroneal nerve (blue line), the deep peroneal nerve (red star), the saphenous nerve (pink star), the sural nerve (green arrow), and the posterior tibial nerve (orange arrow).

Contraindications to sural nerve block include the following: Allergy to anesthetic solution or additives (eg, ester, amide) Injection through infected tissue Severe bleeding disorder or coagulopathy Preexisting neurological damage Patient uncooperativeness (pediatric or elderly patients may need sedation) Technical Considerations Procedure Planning Understanding the arborization of the sural nerve is crucial to a regional block of this nerve. The sural nerve has a contribution from both the tibial nerve and the common peroneal nerve, each of which originates from the sciatic nerve. The contribution from the tibial nerve is the medial sural cutaneous nerve; the common peroneal nerve’s contribution is the sural communicating branch. These two contributions come together to form the sural nerve, which arises in the popliteal fossa and courses superficially after piercing the deep fascia in the posterior calf (see the image below). The sural nerve as it travels down the posterior calf. View Media Gallery The sural nerve continues down the posterior calf and supplies the skin of the posterolateral lower third of the lower leg.

Entering the foot posterior to the lateral malleolus, this nerve supplies the lateral aspect of the foot, including the lateral fifth digit, via the lateral dorsal cutaneus nerve. It supplies the lateral heel via the lateral calcaneal branches. See the images below. Sural nerve dermatome at the level of the posterior calf. View Media Gallery Complication Prevention Infection occurs when the puncture site is not clean. Avoid puncture through infected skin or skin lesion. Be sure to use sterile technique during the procedure, as the risk of infection is insignificant when sterility is properly maintained. Intra-arterial injection [ 7 ] may result in vasospasm and lead to ischemia of the limb tissue. Intravenous injection can lead to systemic toxicity in high doses. Tissue texture changes revealing pallor, bogginess, and cool temperature may indicate that either intravascular injection or vascular compression has occurred. Always draw back on the plunger of the syringe prior to injection to ensure that intravascular placement has not taken place.

Alpha-adrenergic antagonists (eg, phentolamine 0.5-5 mg diluted 1:1 with NaCl 0.9%) can be administered by local infiltration to relieve arterial vasospasm secondary to intra-arterial injection. [ 8 ] Patients may develop paresthesia, sensory deficits, or motor deficits secondary to inflammation of the nerve. Most often, this type of neuritis is transient and resolves completely. During the procedure, pull back gently after inducing a paresthesia so as to not inject the nerve directly. Make sure to document a complete neuromuscular examination both before and after the procedure. [ 9 ] Reports of significant hemorrhage during regional anesthesia are rare, even in patients with blood coagulopathies. [ 10 ] A hematoma may develop with intravascular puncture. If prolonged bleeding occurs, apply direct pressure and elevate the limb. Allergic reactions to local anesthetics occur at a rate of 1%. [ 8 , 11 ] Reactions range from delayed hypersensitivity (type IV) to anaphylactic (type I).

[ 12 ] Although rare, the most common cause of such allergic reaction is the preservative in the local anesthetic solution. Preservative-free lidocaine (found in cardiac preparations) is an alternative because it does not contain the preservative. Alternatively, a 1-2% diphenhydramine solution can be used as a local anesthetic. [ 8 ] The dose of 1% lidocaine without epinephrine should not exceed 5 mg/kg. If lidocaine with epinephrine is used, total dose should not exceed 7 mg/kg. Systemic toxicity manifests in the central nervous and cardiovascular systems. [ 11 , 13 ] Signs such as tremors, convulsions, tachycardia, or respiratory compromise should alert the physician to stop the procedure and reassess the patient. Next: Periprocedural Care Patient Education & Consent Explain the procedure, benefits, risks, and complications to the patient and/or patient’s representative, and inform the patient of the possibility of paresthesia during the procedure. Obtain informed consent in accordance with hospital protocol.

Equipment Equipment for sural nerve block includes the following: Needle, 4 cm, 25 G Needle, 18 G Antiseptic solution (eg, povidone iodine [Betadine] or chlorhexidine gluconate [Hibiclens]) with skin swabs Alcohol swabs Facial mask with eye shield Sterile gauze Equipment is shown in the image below. Equipment needed for regional block. Patient Preparation Anesthesia The 2 main classes of local anesthetics currently in use are amino esters and amino amides. Both inhibit ionic fluxes required for the initiation and conduction of nerve impulses. [ 14 ] Lidocaine, the most commonly used anesthetic, has a fast onset of action and a duration of action of 30-120 minutes, which is increased to 60-400 minutes with the addition of epinephrine. The total cumulative dose of lidocaine to be infiltrated is 5 mg/kg (not to exceed 300 mg) if lidocaine without epinephrine is used, and 7 mg/kg (not to exceed 500 mg) if lidocaine with epinephrine is used.

Anesthetic preparations that contain epinephrine are commonly used in the emergency department. Epinephrine induces vasoconstriction, which decreases the amount of local bleeding at the site of injection. In addition, it increases the duration of action of the anesthetic with which it is combined. Despite these advantages, the vasoconstrictive properties of epinephrine may contribute to tissue hypoxia, and its use should be avoided in areas of poor perfusion (ie, fingers, toes, penis, ears, nose). Topical anesthetics may be needed in children or uncooperative adults. Consider the use of a lidocaine, epinephrine, and tetracaine topical preparation or lidocaine/prilocaine emulsion (EMLA) cream. Pediatric or elderly patients may require additional sedation for compliance. Consider a hematoma block or bier block to attain more effective analgesia when a fracture exists or when more extensive manipulation of the foot is expected. [ 15 , 16 ] Adding a buffering solution, like sodium bicarbonate, can significantly decrease the pain of the injection when performing a nerve block.

[ 10 , 8 ] Add 1 mL of sodium bicarbonate (44 meQ/50 mL) to 9 mL of lidocaine. Warming the anesthetic solution to body temperature can significantly decrease the pain of the injection. [ 8 ] When unassisted, tape a bottle of lidocaine upside down to the wall before starting the procedure. If more anesthetic is needed during the procedure, it can be obtained from this bottle without compromising the sterility of gloves and equipment. Positioning Position the patient prone, with the ankle elevated by a pillow or rolled sheet to optimize comfort. Alternatively, the patient may sit or lay supine with the affected leg internally rotated and the ankle elevated on pillow or rolled sheet. Equipment preparation and proper patient positioning may make the difference between success and failure. Previous Technique Approach Considerations Perform and document neurovascular and musculoskeletal examinations prior to the procedure. Testing the sural nerve prior to block includes sensation of posterolateral calf and sensation of the lateral fifth digit (see the images below). Sural nerve dermatome at the level of the posterior calf. View Media Gallery Approach for Sural Nerve Block Using nonsterile gloves, expose the area of injection and identify the landmarks.

Locate the posterior border of the lateral malleolus and the Achilles tendon (see the image below). Site adjacent to the Achilles tendon. Mark the site just lateral to the Achilles tendon, between the 2 landmarks, as shown in the images below. Mark the site adjacent to the Achilles tendon. View Media Gallery Be sure to not inject within the Achilles tendon. Wipe the area with an alcohol pad and clean the site thoroughly with antiseptic solution, moving outward in a circular fashion (see the image below). Betadine preparation. View Media Gallery Open a sterile drape and place the syringe, needle, and gauze on the tray, maintaining sterility. Put on sterile gloves. Attach the 18-G needle to the 10-mL syringe and draw up the lidocaine. Then, change to the 25-G needle. Place a skin wheal at the site marked. Advance the needle through the skin wheal, angling toward the lateral malleolus. Inject 5-7 mL of lidocaine in a transverse line until the lateral malleolus is reached. See the image below. Advance the needle toward the lateral malleolus.

Calor and rubor of the foot from loss of sympathetic tone may be noted initially. Successful anesthesia of the areas noted heralds a successful sural nerve block. Previous References Crystal CS, Blankenship RB. Local anesthetics and peripheral nerve blocks in the emergency department. Emerg Med Clin North Am. 2005 May. 23(2):477-502. [Medline] . Salam GA. Regional anesthesia for office procedures: Part II. Extremity and inguinal area surgeries. Am Fam Physician. 2004 Feb 15. 69(4):896-900. [Medline] . Russell DF, Pillai A, Kumar CS. Safety and efficacy of forefoot surgery under ankle block anaesthesia. Scott Med J. 2014 May. 59 (2):103-7. [Medline] . DeOrio JK, Gadsden J. Total ankle arthroplasty and perioperative pain. J Surg Orthop Adv. 2014 Winter. 23 (4):193-7. [Medline] . Myerson MS, Ruland CM, Allon SM.

Regional anesthesia for foot and ankle surgery. Foot Ankle. 1992 Jun. 13(5):282-8. [Medline] . Younger DS. Peripheral nerve disorders. Prim Care. 2004 Mar. 31(1):67-83. [Medline] . Greensmith JE, Murray WB. Complications of regional anesthesia. Curr Opin Anaesthesiol. 2006 Oct. 19(5):531-7. [Medline] . McGee D. Local and topical anesthesia. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: WB Saunders; 2004. 541-5. Borgeat A. Neurologic deficit after peripheral nerve block: what to do?. Minerva Anestesiol. Jun 2005. 71(6):353-5. [Medline] . Reichman EF, Tolson DR. Regional nerve blocks (regional anesthesia). Reichman EF, Simon RR, eds. Emergency Medicine Procedures. New York, NY: McGraw-Hill; 2004.

965-81. Gmyrek R. Local anesthesia and regional nerve block anesthesia. Medscape Reference. February 7, 2007. [Full Text] . Haugen RN, Brown CW. Case reports: type I hypersensitivity to lidocaine. J Drugs Dermatol. 2007 Dec. 6(12):1222-3. [Medline] . Ludot H, Tharin JY, Belouadah M, Mazoit JX, Malinovsky JM. Successful resuscitation after ropivacaine and lidocaine-induced ventricular arrhythmia following posterior lumbar plexus block in a child. Anesth Analg. 2008 May. 106(5):1572-4, table of contents. [Medline] . Norris RL Jr. Local anesthetics. Emerg Med Clin North Am. 1992 Nov. 10(4):707-18. [Medline] . Crystal CS, Miller MA, Young SE. Ultrasound guided hematoma block: a novel use of ultrasound in the traumatized patient. J Trauma.

2007 Feb. 62(2):532-3. [Medline] . Luhmann JD, Schootman M, Luhmann SJ, Kennedy RM. A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children. Pediatrics. 2006 Oct. 118(4):e1078-86. [Medline] . Media Gallery Areas of anesthetization to complete an ankle block. This block requires anesthetization of 5 nerves for complete sensory block below the ankle. The areas to anesthetize include a line along the anterior ankle for the superficial peroneal nerve (blue line), the deep peroneal nerve (red star), the saphenous nerve (pink star), the sural nerve (green arrow), and the posterior tibial nerve (orange arrow). Equipment needed for regional block. The sural nerve as it travels down the posterior calf. Sural nerve dermatome at the level of the posterior calf. Sural nerve dermatome at the level of the sole of the foot.

Dermatome map of sural nerve contributions at the level of the anterior lower leg and anterior foot. Site adjacent to the Achilles tendon. Betadine preparation. Mark the site adjacent to the Achilles tendon. Marked site adjacent to the Achilles tendon. Advance the needle toward the lateral malleolus. of 11 The sural nerve – the appendix of the nervous system? | noijam The sural nerve – the appendix of the nervous system? By timcocks0noi , April 20, 2015 The sural nerve is a somewhat underrated nerve – most people are taught that it is a sensory branch that innervates the lower postero-lateral part of the leg and the lateral side of the foot. The fact that it is the most common donor nerve for an autologous graft might be mentioned as an aside – suggesting that just like an appendix, one can live happily without it (if not too bothered by a partially numb foot). Although the sural nerve and appendix might not be essential for life, both structures can have significant clinical relevance.

Clinically significant Only a few days after we published a study on the neurodynamics of the sural nerve , a colleague from Norway shared the story of an elite runner with posterior ankle pain. The runner’s pain had started 2 months earlier when he had slipped on an icy road while training. Reported as initially nothing more than a “stretch”, it gradually became more painful. The pain, about a 4/10 while running, was located above his lateral malleolus and over his Achilles tendon. The pain was reported as becoming more diffuse while running, and more intense with squatting and dorsiflexion. Calf stretches, massage, and a week of no running and NSAIDs, had made little difference. Achilles tendinopathy, peroneus muscle dysfunction, a fatigue fracture and perhaps anterior impingement might come to mind, but the sural nerve, that underrated sensory branch, also runs in close proximity [Fig 1: Anatomy picture]. Further examination revealed over-pronation of his foot, mild patella tilting, poor hip control during unilateral leg stance and corresponding hip muscle weakness.

Assessment of the Achilles tendon and peroneal muscles did not reveal abnormalities, but a modified SLR for the sural nerve and palpation of the sural nerve reproduced his symptoms. A review of the anatomy The main sural nerve is a continuation of the tibial nerve, traveling distally between the heads of the gastrocnemius. Near the lower limit of the gastrocnemius, the sural nerve becomes subcutaneous and is joined by a communicating branch of the common fibular nerve (although this is variable). Click to enlarge © Noigroup Publications. Used with Permission The sural nerve then runs lateral to the Achilles tendon, behind the lateral malleolus and along the lateral border of the foot: Click to enlarge. WARNING: some readers may find the image graphic Sural nerve pathology can be caused by internal factors, such as compression due to fascial thickening, increased calf muscle mass, local scar tissue, mass-lesions (tumours), haemorrhage or abscess, or external factors, such as tight ski-boots, casts or tight footwear. Injury to the sural nerve can occur from an inversion ankle sprain, fracture of direct blow.

The neurodynamics of the sural nerve The neurodynamic test for the sural nerve (SLRSURAL) is similar to other lower limb neurodynamic tests, but specificity for the sural nerve is added with foot positioning and order of movement. For SLRSURAL, the ankle and foot are first moved into dorsiflexion and inversion to load the dorsolateral ankle and foot structures, including the sural nerve: SLR (sural) Step 1 © Noigroup (2015) Used with permission Hip flexion is then added as a sensitising manoeuvre: SLR (sural) Step 2 © Noigroup (2015) Used with permission With the foot and ankle positioning maintained: Foot and Ankle position during SLR (sural) © Noigroup (2015) Used with permission The biomechanical rationale for this procedure is that once the dorsolateral ankle and foot structures are placed under load by initial positioning of the foot, strain in the sural nerve can be selectively and somewhat exclusively increased with the addition of hip flexion. Reproduction or modulation of symptoms with hip flexion suggests sural nerve (or perhaps more broadly, nervous system) involvement.

Although there is little research on the reliability or validity of any clinical test for the sural nerve currently, our recently published article (linked above) demonstrated that hip flexion did increase the strain in the sural nerve in cadaveric specimens, providing biomechanical support for the SLRSURAL. Back to the runner in the clinic Based on the neurodynamic findings, management was quite straightforward. The patient was educated about the problem and what could be done about – including what he could do himself. Neurodynamic mobilisation of the sural nerve was undertaken with a home program provided. Some hip and balance exercises were prescribed to address other issues picked up during examination. The patient was seen on four occasions. He is training happily again and is looking forward to the Norwegian athletics championships. Although the exact pathomechanism is often difficult to determine, being more aware of this ‘forgotten’ nerve and considering neurodynamics as part of a rehabilitation program may bring some relief to runners (and others) with persistent posterior-lateral ankle pain. -Terje Skulstad Michel will be teaching Mobilisation of the Neuroimmune System in Sydney .

Based on the latest evidence, the Mobilisation of the Nervous System course has been updated and re-written ‘from the basic science up’, integrating the neuroimmune system as a critical player in learning, memory, movement and sensitivity. The MONIS course provides a clinical reasoning framework to identify those patients who will benefit from neurodynamic mobilisation and the essential practical skills to examine and manage the physical health of the nervous system. Adelaide 24-25 July and Sydney 1-2 August 2015 Share this: 3 Responses to “The sural nerve – the appendix of the nervous system?” davidbutler0noi Sural nerve - Location, Function, Anatomy and Pictures Sural nerve By Madhulima Acharya on August 19, 2013 in Nervous System Sural nerve Definition It is a sensory nerve in the lower leg that lies close to the small saphenous vein, situated in the calf. As the bundle of fibers form a branch of the femoral nerve, it is also known as “short saphenous nerve”.

Sural nerve Origin The nerve normally emerges from the junction of the medial sural cutaneous with the peroneal anastomotic branch of the lateral sural cutaneous nerve. Sural nerve Location It is specifically located in the lower lateral leg and lateral aspect of the foot. Sural nerve Innervation It innervates the muscles of lateral and posteror third of leg as well as the lateral aspect of foot and heel. Sural nerve Anatomy As aforesaid, it is purely a sensory nerve and does not consist of motor fibers. The short saphenous nerve initially courses posterior between the heads of the gastrocnemius muscle. It runs down and passes near the lateral margin of the Achilles tendon, which is present in the tendon of the posterior leg and lies with the small saphenous vein. Later, it enters the gap between the lateral malleolus and the calcaneus. It continues as the lateral dorsal cutaneous nerve below the lateral malleolus and joins the intermediate dorsal cutaneous nerve on the dorsum of the foot. The terminal branches of the nerve communicate with the collateral branches off of the common tibial and fibular nerve. It comprises of spinal nerve roots from S1 and S2.

It acts as a guide to the tibial nerve since it lies superficial to deep fascia below the knee. It is in close approximation with the peroneus brevis tendon. Distribution of the cutaneous nerves is clearly visible on the sole of the foot when examined closely. Sural nerve Function It mainly supplies the branches to the skin on the back of the leg before continuing as the cutaneous nerve along the outside of the foot and little toe. Most importantly, the nerve is used to relay sensory information about the lower calf and external foot to the brain. Since the short saphenous nerve is in close proximity to the skin, it finds greater use in nerve biopsy. In this procedure, a 3-5cm section of the nerve is harvested at the level of the ankle. Microscopic evaluation of the sample may provide some clues to diseases like demyelination, sarcoidosis, amyloidosis, and leprosy. It is also a common source of nerve cable graft material. Here, a piece of the donor nerve is excised and transplanted to the area of neurological damage in order to restore muscle function, particularly in the case of damaged limbs and ulnar nerve injury.

Patients with sexual dysfunction post prostate cancer surgery often undergo sural nerve transplantation to regain the normal libido. However, there are no specific CPT codes for nerve grafting. It is also required for nerve conduction studies to detect demyelination. Doctors often use the median superficial sural artery and nerve to create a flap for correcting anomalies around the foot as well as the ankle. Innumerable studies have been globally conducted to further analyze the anatomical variations of the nerve. In many surgical interventions, the nerve is often blocked to carry out the required procedure smoothly. These may include: Ankle block to correct a fractured/dislocated ankle Elimination of a foreign material in the lateral posterior calf Repair of wounds Sural nerve Diseases Severe trauma can often result in sural neuropathy, a common neurological problem caused due to a damaged nerve. It is a debilitating disorder that manifests into pain, and may cause numbness and tingling. This may eventually manifest into nerve palsy, which is evident during Tinel’s test.

Some of its causes include: Ankle sprain/fracture Ganglion cyst Vasculitis Similarly, certain physiological abnormalities can lead to nerve entrapment/compression due to direct pressure on the short saphenous nerve, and produce symptoms akin to neuropathy. As the pathway of the nerve includes the fibrous arcade, it is the most common site for nerve impingement. In most cases, the left nerve is highly affected. Reduction of frictional irritation in this region with myofascial or active release is the only treatment available for this ailment. However, certain mobilization techniques such as neural flossing and nerve gliding exercises can ameliorate the painful symptoms to some extent since these methods involve regular stretching of the affected nerve. Irritation or injury to the nerve is known to cause sural neuritis/neuralgia, a bothersome condition marked by a burning pain in the lower leg, particularly in the heels. For the same reason, the tissues surrounding the sensory nerve can enlarge or swell and cause neuroma. Ablation of the nerve may help in reducing the pain. Some individuals may even develop focal lesions in the short saphenous nerve, which can be easily diagnosed by MRI scan and ultrasound imaging.

In few instances, the nerve could get severely affected during varicose vein surgery. Sural nerve Pictures What is the Sural Nerve? (with pictures) What is the Sural Nerve? Last Modified Date: 29 December 2016 Copyright Protected: 10 hilariously insightful foreign words The sural nerve, also known as the short saphenous nerve , is a sensory nerve in the lower leg of humans. It lies close to the short saphenous vein, a major vein in the calf, and may begin anywhere from behind the knee to just below the ankle. The nerve is often used for biopsies and grafts. This nerve usually begins where the medial sural cutaneous nerve and the lateral sural cutaneous nerve, two nerves in the lower leg, come together. For most individuals, this occurs quite low on the leg, even at or below the ankle. For a few, however, the nerve may begin as high as the back of the knee. In some people, the sural nerve is simply a continuation of the medial sural cutaneous nerve. The nerve travels down the calf not far under the surface of the skin.

It passes near the Achilles tendon and ends in the space between the heel bone and the lateral malleolus, the bony bump on the outside of the ankle. The nerve continues on into the foot, eventually reaching the little toe, but from the ankle on is considered to be a separate anatomical part called the lateral dorsal cutaneous nerve. The body uses this nerve to convey sensory information about the lower calf and outer foot to the brain. Damage to the nerve can cause severe pain in the leg or foot. This can be treated by removing part of the nerve, which usually results in an area of numbness around the ankle and side of the foot. Nearby nerves will often grow to compensate, restoring most of the feeling to the damaged area. Due to its proximity to the skin, the redundancy of nerves in the surrounding tissue, and its relative unimportance to essential body functions, the sural nerve is a popular candidate for removal as part of a biopsy. To perform a nerve biopsy, the surgeon first injects a local anesthetic . Using the short saphenous vein as a guide, the sural nerve is located. A small piece, usually about an inch (2.5 cm) long, is removed with a quick, sharp cut.

The wound is stitched shut and covered with saline-moistened gauze. The sample is then examined using a microscope to look for evidence of disorders including amyloidosis, sarcoidosis, leprosy, and demyelination. For similar reasons, the sural nerve is also often used as the donor nerve in nerve grafts. In a nerve graft, a piece of healthy nerve is transplanted to an area where nerve damage has occurred. It is spliced with the existing nerves in order to restore muscle function or sensation. The procedure is commonly performed to restore feeling to damaged limbs. Increasingly, the sural nerve may be transplanted to the pelvic area in an attempt to restore lost sexual function after prostate cancer surgery. Ad Femoral Nerve - Anatomy Pictures and Information Home > Nervous System > Nerves of the Leg and Foot > Femoral Nerve Femoral Nerve The femoral nerve is the major nerve that serves the tissues of the thigh and leg, including the muscles and skin. While the much larger sciatic nerve also passes through the thigh on its way to the lower leg and foot, only the femoral nerve innervates the tissues of the thigh.

Nerve signals carried by the femoral nerve are crucial to the function of the legs, including standing, walking, and running. The femoral nerve begins as the largest nerve to extend from the lumbar plexus in the lower back as a combination of fibers from the L2, L3, and L4 spinal nerves.... Move up/down/left/right: Click compass arrows Rotate image: Click and drag in any direction, anywhere in the frame Identify objects: Click on them in the image 2D Interactive 3D Rotate & Zoom Change Anatomical System Change View Angle Full Femoral Nerve Description [Continued from above] . . . From the lumbar plexus it extends with the fibers of the psoas major muscle inferiorly through the abdomen along the anterior surface of the hip bone. As it passes through the abdomen, a branch of the femoral nerve extends to provide nervous connections to the iliacus muscle, a flexor of the thigh. From the abdomen the femoral nerve next passes deep to the inguinal ligament in the groin and crosses the hip joint to enter the femoral region.

In the femoral region, the femoral nerve separates into two nerve trunks - the anterior and posterior divisions - before further dividing into many smaller branches throughout the anterior and medial thigh. Several cutaneous and muscular branches split from the anterior branch of the femoral nerve to carry nerve signals to specific targets in the thigh and leg. The medial cutaneous branch spreads vertically throughout the skin of both the medial thigh (through its anterior branch) and the medial leg (through its posterior branch). Extending parallel to the medial branch, the intermediate cutaneous branch spreads throughout the anterior surface of the thigh. Muscular branches of the anterior femoral nerve extend to the pectineus and sartorius muscles, which flex, adduct, and abduct the thigh. The posterior branch of the femoral nerve forms several important branches that serve the leg and are vital to the extension of the knee. Its muscular branches innervate the four quadriceps muscles (rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius), which flex the thigh at the hip and extend the leg at the knee.

The cutaneous branches form the saphenous nerve, the largest branch of the femoral nerve, which runs parallel to the saphenous vein in the subcutaneous layer toward the lower leg. In the leg, the saphenous nerve innervates the skin along the anterior and medial surfaces. The femoral nerve is a mixed nerve, meaning that it combines both afferent and efferent fibers in the same nerve. Afferent nerves carry important sensory information from the tissues of the thigh and leg (especially the skin) to the central nervous system for processing. Efferent neurons perform the essential function of carrying signals to the muscles of the thigh and leg to control their tension and movement. Thus the femoral nerve functions like a two-lane road, carrying information both to and from the brain through two sets of one-way neurons. These signals permit the body to react to stimuli and produce a variety of movements, including walking, running, and maintaining balance.

Prepared by Tim Taylor, Anatomy and Physiology Instructor Sural region | definition of sural region by Medical dictionary Sural region | definition of sural region by Medical dictionary su·ral re·gion [TA] the muscular swelling of the back of the leg below the knee, formed chiefly by the bellies of the gastrocnemius and soleus muscles. [so̅o̅′rəl] Etymology: L, sura, calf of the leg the calf of the leg. It is formed by the bellies of the gastrocnemius and soleus muscles. su·ral re·gion (sūr'ăl rē'jŭn) [TA] The muscular swelling of the back of the leg below the knee, formed chiefly by the bellies of the gastrocnemius and soleus muscles. Synonym(s): calf . Patient discussion about sural region Q. I have just developed a pain in my calf - feels like it clicks when I walk, and is a sharp pain I first noticed this problem this morning. As I stepped out of my car, I felt a sharp pain in my left calf, and it has gone worse as the day has gone on.

No pain until I walk. A. hmmm...now as i think of it- fatman's answer seems more logical. but usually people can tell the difference between strained muscle and other stuff. if it was just a pulled muscle he would have thought of it and naturally massage the area. no?

Question: In which part of the body is the 'Sural Nerve'?
Answer: LEG